I was once greeted at the home of a young woman named Lia who was bedridden since her recent delivery. The narrow, uneven staircase leading to her 3-piece apartment, on the second floor immediately struck me. Three plastic chairs and some dusty decorations adorned the living room. I was climbing the shaky staircase when her husband Manno appeared to welcome me. The couple was forced to marry 4 years prior, to escape public shaming when Lia unexpectedly became pregnant with their first daughter Zina. Zina was inside, busy undoing her braids. She was so unusually calm and silent that Manno asked her if everything was alright, with a strong smell of alcohol on his breath. Although she appeared serene, in reality, she was feeling like her world was crumbling ever since her mother, Lia, gave birth to her little sister, since then Lia’s behavior had started to change.

Manno led me into the bedroom where Lia was resting. A dirty-white mosquito net covered the bed. Children toys and elementary school books stood on cupboards and small tables. I quickly understood that the entire family was living in the same small space. Lia stared aloofly at the ceiling. The newborn girl was laying down to her left. While Manno was getting me a chair, I noticed how Lia dropped quick frightened glances towards the baby from time to time. As Manno entered the room again staring down, ashamed, Lia uttered insulting and incoherent words and even threatened to choke her own newborn baby. Manno instantly presented his deepest apologies to me, for his wife’s delirium. But I wasn’t surprised at all because I am familiar with such symptoms- confusion, paranoia, agitation, hallucinations and sleeplessness– evocative of a post-partum psychosis, which is a psychiatric illness affecting some women after delivery.

Friends and family think that jealous neighbors took advantage of Lia’s pregnancy to cast a spell on her. Her father has even proposed that she travel to the North of Haiti to find him, to try to ward off this miserable fate. In the northern town where Lia’s father lived, he was very respected thanks to his land, livestock and his expertise in traditional medicine, despite his proclaimed Christian beliefs. Manno informed me that even the doctor they contacted in Port-au-Prince had recommended they go visit a hougan, a Vodou priest that sometimes serves as healer. It is difficult to be clear about the impact of traditional or religious practices on mental illnesses (especially if these diseases are observed from the perspective of Western medicine, as in my case), but I am, nonetheless, aware that they are often the only resource for people suffering from such diseases in Haiti, especially in remote areas. And, Lia or her entourage’s interpretation of her disease, whether it may sound irrational to you or not, is already a step towards treatment. How she understands her disease is important to her healing. If she thinks it is a supernatural misfortune, her caregiver should not disregard her conception.

However, in my mind there was no supernatural misfortune. Unwanted pregnancy, a history of chronic major depressive disorder or depression during pregnancy remain factors that make many women vulnerable to mental illness after childbirth. In fact, although these factors are numerous (biological, psychological and social), in Lia’s case, the living conditions were the most likely cause. Many stressors in her life as a Haitian woman, as a wife, as a mother, as an employee, were always present prior to her pregnancy, but were perhaps seen as isolated situations that have all now bubbled to the surface. Many Haitians are fragmented in this way, as sections of their history are separated but yet unknowingly linked, and can be a source for many ailments.

To provide some context: poverty affects more than 80% of the Haitian population and social exclusion and alienation often go hand in hand. Despite counting for 56% of the population, women are too often denied the most basic rights. When it comes to mental health, such a context is hardly favorable. Opportunities for prosperity are available to the few who have had access to the right education, those who can take advantage of a broken system and the very few born within a supportive environment. On the other hand, elements that could promote resilience and health, such as family support, are rare or poorly integrated.

But, in Haiti, the relationship with mental illnesses is difficult even among the more privileged. No matter the systems of thought, traditional or modern, most of the times, patients are simply dismissed as “mad” or possessed by an evil spirit, regardless of the mental illness the individual suffers from. Local obstetricians (in case of pregnancy-related mental illnesses) and mental health professionals, psychiatrists and psychologists, struggle to address the most pressing health issues concerning women. Numerous medical NGOs also support maternal health in Haiti. But while they often heal the body, mostly focusing on communicable diseases, the mind is highly overlooked. So women usually don’t freely express their real preoccupations and needs, reinforcing the barriers to proper care.

The last time I asked after Lia, she had joined her father’s lakou in the North and was taking pills prescribed by a psychiatrist while simultaneously going through mystical treatment. I was happy to hear that she was doing better. That was good news for her baby. But as I said goodbye to Manno and he replied, the scent of his breath reminded me of someone I had forgotten to ask about. “How’s Zina doing, by the way?” I asked as memories of her sad face resurfaced. – “She’s doing good replied Manno, she’s at school right now, I took her this morning. With Lia gone, I’m the one taking care of her” he added. I nodded with the largest smile I could muster and told him our traditional. “ankouraje.” But I left with a heavy heart, full of fear and prayer for Zina.

Fairly called Poto Mitan in Haitian Creole, women account for 50.49% of the Haitian population and represent the center pillar of most households. From commerce to education, their contributions to the society are undeniable. As the prosperity of the nation relies on its citizen’s well-being, it is no surprise that women’s health is a public health priority when it comes to the national health policies. But despite the efforts, unsafe abortion remains unfortunately a scourge as prevalent as poorly addressed.

I recall my last shift at Chancerelles’ maternity ward where a 16 year-old pregnant girl presented with intense abdominal pain and massive vaginal bleeding. At first, she did not admit any medication ingestion prior to the onset of her symptoms. But as we pursue the medical investigations, her 30-year-old boyfriend confessed that he had provided her with 4 pills of an over-the-counter drug known to provoke abortion in pregnant women. For the gynecology residents, it was a routine and classic case. Yet openly discussing unsafe arrest of pregnancy in Haiti is controversial since it’s so much of a taboo.

The World Health Organization (WHO) defines unsafe abortion as a procedure for terminating a pregnancy performed by persons lacking the necessary skills or in an environment not in conformity with minimal medical standards, or both. Every year, 50.000 women, mostly from Latin America and Caribbean countries, die from consequences of unsafe abortion. According to the article 262 of the Haitian penal code, induced abortion no matter where or who performs it, is a criminal act and legally punished nationwide. But regardless of the law (or maybe because of it), complications of clandestine abortions are common motives of visit in general and obstetrical care facilities.

Carole, the latest patient I examined, was going through her second abortion experience and presented with severe anemia after 15 days of bleeding. When she got pregnant, economic difficulties arose, urging her to take the decision with her husband’s consent. But the specialized hospital she visited wouldn’t provide the desired services as forbidden by the law. So she turned to a clandestine clinic, even when the fees were high. As we shared our opinions, she said that it would be beneficial for women to abort safely with optimal medical assistance because the absence of a legal framework for safe abortion and technical capacities almost took her life away.

A few days later an obstetrician and HIV care specialist told me that to alter the perilous consequences of unsafe abortion in Haiti, it would be best to decriminalize it. Among the 530 women deaths per 100.000 inhabitants per year in Haiti, 120 are attributed to unsafe abortion. Fortunately, in the last quinquennium, the Ministry of Health has debated the subject and elaborated a new bill with several social groups to allow abortion for medical purpose and in rape cases. This is one step forward in the modernization of women’s health in Haiti even when it hasn’t reach the parliament yet.

But the main causes of induced abortion being socio-economic status, maybe the bill should also include women who desire to arrest their pregnancy for any reason other than congenital malformations or rape. It would be better if every woman could openly discuss it with their doctors.

Because it is the State’s duty to guarantee optimal health care to the population, and health is not restricted to the body. It includes mental and social well being.

It would be valuable to couple activism with effective health communication. Because often, the barriers to improving women’s health in Haiti are some erroneous traditional beliefs. My intention here is not to downplay any religious or cultural values, as some have actually improved women’s health. My advocacy is to conduct proper scientific studies on this public health issue and clearly communicate the best ways to prevent the consequences. After all, prevention costs exponentially less than complication management and as the recently published statistics show, the State’s funds have long been depleted.